Failure of anticoagulant thromboprophylaxis: risk factors in medical-surgical critically ill patients*.

Abstract

OBJECTIVES:

To identify risk factors for failure of anticoagulant thromboprophylaxis in critically ill patients in the ICU.

DESIGN:

Multivariable regression analysis of thrombosis predictors from a randomized thromboprophylaxis trial.

SETTING:

Sixty-seven medical-surgical ICUs in six countries.

PATIENTS:

Three thousand seven hundred forty-six medical-surgical critically ill patients.

INTERVENTIONS:

All patients received anticoagulant thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin at standard doses.

MEASUREMENTS AND MAIN RESULTS:

Independent predictors for venous thromboembolism, proximal leg deep vein thrombosis, and pulmonary embolism developing during critical illness were assessed. A total of 289 patients (7.7%) developed venous thromboembolism. Predictors of thromboprophylaxis failure as measured by development of venous thromboembolism included a personal or family history of venous thromboembolism (hazard ratio, 1.64; 95% CI, 1.03-2.59; p = 0.04) and body mass index (hazard ratio, 1.18 per 10-point increase; 95% CI, 1.04-1.35; p = 0.01). Increasing body mass index was also a predictor for developing proximal leg deep vein thrombosis (hazard ratio, 1.25; 95% CI, 1.06-1.46; p = 0.007), which occurred in 182 patients (4.9%). Pulmonary embolism occurred in 47 patients (1.3%) and was associated with body mass index (hazard ratio, 1.37; 95% CI, 1.02-1.83; p = 0.035) and vasopressor use (hazard ratio, 1.84; 95% CI, 1.01-3.35; p = 0.046). Low-molecular-weight heparin (in comparison to unfractionated heparin) thromboprophylaxis lowered pulmonary embolism risk (hazard ratio, 0.51; 95% CI, 0.27-0.95; p = 0.034) while statin use in the preceding week lowered the risk of proximal leg deep vein thrombosis (hazard ratio, 0.46; 95% CI, 0.27-0.77; p = 0.004).

CONCLUSIONS:

Failure of standard thromboprophylaxis using low-molecular-weight heparin or unfractionated heparin is more likely in ICU patients with elevated body mass index, those with a personal or family history of venous thromboembolism, and those receiving vasopressors. Alternate management or incremental risk reduction strategies may be needed in such patients.

• Authors: Wendy Lim, Maureen Meade, Francois Lauzier, Ryan Zarychanski, Sangeeta Mehta, Francois Lamontagne, Peter Dodek, Lauralyn McIntyre, Richard Hall, Diane Heels-Ansdell, Robert Fowler, Menaka Pai, Gordon Guyatt, Mark A Crowther, Theodore E Warkentin, P J Devereaux, Stephen D Walter, John Muscedere, Margaret Herridge, Alexis F Turgeon, William Geerts, Simon Finfer, Michael Jacka, Otavio Berwanger, Marlies Ostermann, Ismael Qushmaq, Jan O Friedrich, Deborah J Cook, PROphylaxis for ThromboEmbolism in Critical Care Trial Investigators
• Journal: Critical care medicine (Crit Care Med) Vol. 43 Issue 2 Pg. 401-10 (Feb 2015) ISSN: 1530-0293 [Electronic] United States
• PMID: 25474533 (Publication Type: Journal Article, Multicenter Study, Randomized Controlled Trial, Research Support, Non-U.S. Gov't)

Chemical References

• Anticoagulants

Topics

• APACHE
• Age Factors
• Aged
• Aged, 80 and over
• Anticoagulants (administration & dosage)
• Body Mass Index
• Chemoprevention
• Clinical Protocols
• Critical Illness (epidemiology)
• Female
• Humans
• Intensive Care Units (statistics & numerical data)
• Male
• Middle Aged
• Pulmonary Embolism (epidemiology)
• Risk Factors
• Venous Thromboembolism (epidemiology, prevention & control)